Doctors differ on treatments for DCIS, or ‘Stage 0’ breast cancer
Up to a quarter of American women newly diagnosed with breast cancer this year will face a once-rare condition that has spurred wide debate in the medical community and left many patients confused about treatment.
The ailment, affecting more than 60,000 newly diagnosed women in the country this year, according to the American Cancer Society, is often referred to as a “stage 0” or “pre-invasive” cancer.
The options for treatment are wide-ranging, including surgery - the current standard, followed up in many cases by radiation or hormone therapy - to a more hands-off approach that favors waiting to see if the disease advances.
The illness is known more commonly by its initials - DCIS - than by its formal name, ductal carcinoma in situ, referring to the milk ducts where the abnormal cells are found. They can multiply there and spread to other tissues in the breast or remain confined and thus noninvasive.
So far, there is no tried-and-true test to determine which DCIS lesions will progress to full-blown, invasive breast cancer and which will cause no further bother, doctors say.
A new study released last month, meanwhile, has fueled further debate surrounding the condition and its treatment. Among their findings, researchers concluded that there was no significant difference in survival among women who underwent surgery - removing the breast or a portion of the breast, or undergoing partial removal followed by radiation. Some physicians have found support in the findings for a less aggressive approach to treatment for some of their patients, based on their conditions.
Still, standard treatment is much the same as it would be for invasive breast cancer: cut it out and, in many cases, follow up with radiation or hormone therapy.
That’s just fine with patients like Toni Dettling of Rohnert Park, who had a double mastectomy last year after imaging turned up signs of DCIS in both breasts. She had begun to notice dimpling and retraction of her nipple on one side in the months leading up to the mammogram that prompted further testing and diagnosis.
“I don’t want to take a chance and have something come up again,” said Dettling, 53. “I right away opted for a double mastectomy.”
Ann Tremblay of Santa Rosa said she, too, embraced her surgeon’s recommendation for a proactive approach to her condition, though she understood it was noninvasive and not life-threatening as diagnosed. She trusted her medical team implicitly, she said, given the expertise that they possessed and she did not. After a lumpectomy in June to remove the abnormal lesion and surrounding breast tissue, she finished up a 30-day course of radiotherapy Friday.
“I have a 10-month-old granddaughter,” said Tremblay, 60. “I want to be around. For her.”
But the medical community is now increasingly facing questions about the best treatment approach to DCIS.
Many believe there is little choice but to act aggressively until more refined biological assessments are available to determine which DCIS lesions present actual risk of invasive disease.
Patients who have just learned of breast cell abnormalities typically aren’t in the mood to gamble on lesser treatment in any case, doctors said. The most common treatment is lumpectomy and radiation in cases where DCIS appears in a single location, doctors said. Mastectomy is more often used when there are multiple lesions or abnormal cells along the length of a duct.
Still, some in the medical field believe radiation is overused and that DCIS is generally over-treated and dealt with on a more urgent basis than is necessary, given that many cases will never progress and that women with DCIS have a high disease-free survival rate of 96 to 98 percent after treatment.
There may be opportunities to wait for a patient’s disease to “declare itself” before taking treatment action at all, depending on the degree of abnormality in the cells and rate of growth, according to Laura Esserman, director of the UC San Francisco Carol Franc Buck Breast Care Center, who is known for advocating a lighter touch in treating DCIS.
Emphasizing that approach over one that combines say, surgery, radiation and hormone therapy right off the bat, can be difficult, said Michael Alvarado, who works with Esserman as a breast cancer surgeon and associate professor of medicine at UCSF.
“We’ve been promoting the concept that DCIS is over-diagnosed, over-treated,” Alvarado said. “It causes a lot of worry with the name - ductal carcinoma - when it’s not even a true cancer.”
DCIS is usually asymptomatic, but often results in tiny calcium deposits in the breast tissue called micro-calcifications.
UPDATED: Please read and follow our commenting policy: